Musical Chairs & The ABCs of SARS-CoV-2 Monoclonal Antibodies

On this article an infectious sicknesses pharmacist discusses some ABCs of SARS-CoV-2 monoclonal antibodies and the way the ever-changing panorama of prevalent variants looks like a sport of musical chairs. 



Authored by means of: Timothy P. Gauthier, Pharm.D., BCPS, BCIDP


Knowledge in this subject is unexpectedly replacing, which might render content material in this web page erroneous or incomplete. Readers are warned to reference number one data assets for answering questions for medical care. Continue with warning.


Article Posted: 17 March 2022

There are lately six SARS-CoV-2 monoclonal antibodies that experience had an FDA Emergency Use Authorization (EUA). They’re bamlanivimab from Eli Lilly, bamlanivimab/etesevimab from Eli Lilly, bebtelovimab from Eli Lilly, sotrovimab (Xevudy) from GlaxoSmithKline, casirivimab/imdevimab (REGEN-COV) from Regeneron, and tixagevimab/cilgevimab (Evusheld) from AstraZeneca. The EUAs for casirivimab/imdevimab and bamlanivimab/etesevimab don’t lately permit to be used in any US territory. Tixagevimab/cilgevimab is for pre-exposure prophylaxis simplest. Sotrovimab can be utilized for remedy however has lesser job in opposition to Omicron BA.2. Bebtelovimab can be utilized for remedy however has restricted medical information to reinforce use.

Monoclonal antibodies be offering passive immunity in opposition to SARS-CoV-2. Their mechanism is other than antiviral medication comparable to molnupiravir (Lagevrio), nirmatrelvir/ritonavir (Paxlovid), and remdesivir (Veklury). Because the monoclonals fall out and in of fashion right through what looks like an never-ending sport of track chairs, there are a large number of issues of differentiation and attention that may be seen. Those are related now and more likely to be related at some point. Thus, this text is advanced to spot and talk about the subject, however impressed by means of a contemporary article about Sesame Boulevard and infectious sicknesses, this might be introduced within the type of the ABCs.

As you undergo this text, if there are any assets you might be on the lookout for, considered one of my favourite one-stop-shops is the HHS/ASP COVID Therapeutics webpage, at which you’ll click on at the tile for the treatment of passion and lots of useful hyperlinks are there in a single position.

A is for Age

Age is the most powerful menace issue for deficient results with COVID-19 and has been used as one of the crucial key components in prioritization tasks right through occasions of monoclonal antibody shortage. View the CDC webpage about folks with sure prerequisites hanging them at upper menace right here.

Age may be a minimize level for one of the EUAs. For instance the sotrovimab limits use to sufferers 12 years and older.

B is for Frame Weight

Like age, huge frame weights (e.g., BMI > 30 for weight problems) are related to deficient COVID-19 results. Then again, frame weight may be one of the crucial necessities present in monoclonal antibody EUAs, which prohibit use in pediatric sufferers to those who are 40 kg or extra. Take a look at each and every monoclonal’s Healthcare Skilled (HCP) Reality Sheet for explicit main points inside each and every EUA.

C is for COVID-19

The NIH COVID-19 Pointers supply main points at the medical spectrum of sicknesses that SARS-CoV-2 may cause. Of significance, monoclonal antibodies have every so often been related to worse results when given for serious or vital COVID-19. Alternatively, remedy of sufferers who’re asymptomatic might not be suitable. Each and every monoclonal will have to be thought to be within the context of which medical shows it’s licensed for.

D is for Direct SARS-CoV-2 Trying out

When used for remedy, the EUAs have required a good direct take a look at for SARS-CoV-2, which may well be both a PCR or antigen take a look at.

Tixagevimab/cilgavimab then again does now not require a direct take a look at, as it’s lately simplest licensed for pre-exposure prophylaxis. Thoughts you checking out can nonetheless be thought to be previous to remedy if worry for an infection is provide.

E is for Publicity

As sufferers in poor health with COVID-19 provide for monoclonal analysis, they are going to inadvertently disclose different folks to the virus. An infection regulate within the context of remedy or post-exposure prophylaxis of COVID-19 deserves attention. For instance, you wouldn’t need an infusion middle the place high-risk most cancers sufferers obtain their remedy to co-mingle with sufferers in poor health with COVID-19.

Additionally at the subject of publicity, not one of the monoclonals with an lively EUA is licensed for post-exposure prophylaxis, however will have to that turn out to be an possibility once more (as it’s been with casirivimab/imdevimab as an example), classification of the publicity might be important. CDC definitions of publicity might be crucial assets for this.

F is for Reality Sheet

As a part of the EUA, the affected person or care giver will have to be supplied with the related reality sheet, which by-the-way can also be laborious to come back by means of in different languages but even so English or Spanish. Some sufferers might decline remedy after reviewing this reality sheet. It is necessary sufferers and caregivers be supplied with this data so they are able to make an educated determination.

Moreover, the HCP Reality Sheet is a vital useful resource. It’s very similar to a bundle insert and the HCP Reality Sheets are up to date quite steadily. It’s been difficult to have HCP Reality Sheet content material up to date with none complex understand, leaving healthcare amenities scrambling to make techniques adjustments. One instance of that is with the dose build up of tixagevimab/cilgavimab from 150mg/150mg to 300mg/300mg. That gave the impression to come utterly instantly for plenty of (if now not all people).

G is for Biggest Chance

Sufferers must be in danger for development to serious COVID-19 or different dangerous results to be thought to be for remedy with the SARS-CoV-2 monoclonals. Because the FDA EUAs have turn out to be extra liberal in what constitutes “in danger”, the ones at largest menace will have to be thought to be for prioritization.

H is for Hospitalization

In america not one of the monoclonals had been licensed to be used in remedy of sufferers hospitalized for COVID-19. They’ve been allowed in sufferers who’re hospitalized for different causes, however occur to obtain COVID-19 (so long as different inclusion/exclusion standards are met). In the UK, casirivimab/imdevimab used to be licensed to be used in sufferers hospitalized for COVID-19.

The fear with use in sufferers hospitalized for COVID-19 is that use has been related to medical worsening. There are information appearing favorable ends up in seronegative hospitalized sufferers handled with casirivmab/imdevimab – however this is a subject for a long run weblog put up!

I is for Indication

The symptoms can come with pre-exposure prophylaxis, remedy, or post-exposure prophylaxis. As each and every monoclonal is regarded as, the present licensed indication will have to be seen. Bear in mind that an agent can have a large number of indications.

J is for Joint Protection Reported

Medicine mistakes and critical hostile reactions will have to be collectively reported to FDA Medwatch in addition to the product’s producer. For instance the sotrovimab HCP Reality Sheet notes those occasions will have to be reported inside 7 calendar days of the healthcare supplier’s consciousness of it, the use of FDA Shape 3500. It additionally notes the prescribing healthcare supplier and/or the supplier’s designee is/are answerable for necessary responses to requests from the FDA for details about hostile occasions and drugs mistakes.

Critical hostile occasions can come with: dying, a life-threatening hostile tournament, inpatient hospitalization, prolongation of current hospitalization, a continual or vital disability or considerable disruption of the power to habits commonplace existence purposes, a congenital anomaly/ delivery defect, or different essential clinical tournament which might require clinical or surgical intervention to stop dying, a life-threatening tournament, hospitalization, incapacity, or congenital anomaly.

Ok is for Kinetics

The half-life of the monoclonals can range significantly, which means that the period in their coverage might not be the similar as repeat dosing is regarded as. The tixagevimab/cilgavimab HCP Reality Sheet to begin with stated shall we re-dose each 6 months for sufferers that persisted to be at-risk and wanted coverage. Now that report says: “The SARS-CoV-2 variants that might be circulating in america when Evusheld might want to be redosed aren’t recognized presently and due to this fact repeat dosing suggestions can’t be made; the Reality Sheets might be revised with repeat dosing suggestions at some point when extra information are to be had.”

L is for Lengthy Remark Duration

All the monoclonals lately require an statement duration of 1 hour. That won’t appear to be a large deal, however whilst you believe it within the context of the quantity of sufferers that can be looking for the treatment and be aware how lengthy the talk over with takes with different consumption/discharge actions, this isn’t a speedy procedure.

The 60 minute post-dose statement is in position because of the chance for infusion/injection-related reactions that can happen, together with anaphylaxis.

M is for Mutations

As mutations have arisen and other variants have turn out to be principal, we’ve performed musical chairs with which monoclonals can also be choices. The HCP Reality Sheets now record the job of each and every monoclonal in opposition to the variants. Here’s a desk I made the use of the entire HCP Reality Sheet information:

You’ll be able to use CDC assets to trace variant predominance and CDC NOWCAST is lovely useful too. Some states and counties additionally document variant predominance information.

N is for Neonatal Dangers

Being pregnant and breastfeeding will have to be incorporated within the screening processes for the monoclonals, together with making the affected person conscious about the chance as opposed to advantages of the remedy choices handy. Basically, the monoclonals seem to be protected for pregnant or breastfeeding moms. You’ll be able to learn extra about this subject right here within the January 2022 Joint Observation from MDH, MN ACOG, Allina Well being, Mayo Hospital, and College of Minnesota commentary on COVID-19 Monoclonal Antibody Use in Being pregnant.

O is for Oxygen

For the ones monoclonals simplest licensed to be used in mild-moderate COVID-19, be aware that an Sp02 under 94% because of COVID-19 places a affected person within the class in serious or vital COVID-19. Due to this fact, when used for remedy, a pre-dose oxygen saturation could also be thought to be to substantiate qualification.

..perhaps O will have to had been for Omicron?… as in what’s Omicron going to do subsequent and the way will that have an effect on which monoclonal antibodies we will use???

Q is for FAQ

Many of us get entry to the HCP Reality Sheets, however the FAQs related to each and every monoclonal antibody have additionally been tremendous useful with follow software of when those therapies can be utilized or navigating nuances. For instance, in finding the sotrovimab FAQ right here, which solutions questions comparable to: “Does the EUA allow using sotrovimab as licensed in sufferers hospitalized for causes instead of COVID-19?”

R is for Course

Tixagevimab/cilgavimab is simplest indicated to be given by way of intramuscular injection. Bebtelovimab is allowed to be given by way of IV push. Sotrovimab is allowed to be given IV over as brief as quarter-hour. Casirivimab/imdevimab used to be licensed for intravenous or subcutaneous management, with intravenous most well-liked for remedy and subcutaneous most well-liked for post-exposure prophylaxis.

The direction of management is not just variable around the monoclonal antibody arsenal, the direction and management directions have additionally been recognized to be changed within the HCP Reality Sheets.

S is for Stewardship

A contemporary learn about of sotrovimab discovered use is related to speedy construction spike gene mutations and is related to sotrovimab resistance. This led authors to name for stewardship for monoclonal antibodies. Similar to antibiotics it sounds as if this can be a “the extra you employ it, the extra you lose it” form of scenario. Within the aforementioned learn about, sufferers handled with sotrovimab had SARS-CoV-2 remoted as much as 24 days after remedy!

T is for Timing

On the subject of remedy of COVID-19, each sotrovimab and bebtelovimab EUAs require remedy with 7 days of symptom onset. Up to now for bamlanivimab, bamlanivimab/etesevimab, and casirivimab/imdevimab it used to be 10 days. It is smart {that a} treatment which affects viral replication be given early within the illness when the virus is replicating probably the most, however it additionally makes it difficult to keep up a correspondence ever-changing standards when what used to be as soon as 10 is now 7.

Timing may even topic for re-dosing of pre-exposure prophylaxis tixagevimab/cilgavimab, as discussed above within the kinetics segment.

U is for Application

Other remedies have other application and this will have to at all times be taken within the context of the person affected person components in conjunction with which variants are most probably prevalent.

The NIH COVID-19 pointers rank desire in remedy choices of non-hospitalized sufferers with COVID-19 as: PO nirmatrelvir/ritonavir (Paxlovid) x5 days > IV sotrovimab (Xevudy) as soon as > IV remdesivir (Veklury) x3 days > PO molnupiravir (Lagevrio)  x5 days = IV bebtelovimab as soon as.

With the oral remedies turning into extra readily to be had, it’s conceivable (if probably not), that SARS-CoV-2 monoclonal antibody application will turn out to be much less.

V is for Verification of Documentation & Eligibility

Verification of key EUA data will have to be thought to be to be constructed into the workflow of monoclonal antibody ordering, allotting, and management. All the EUAs require that “via a technique of stock regulate, healthcare amenities will handle information in regards to the allotting and management of for the use licensed on this letter (i.e., lot numbers, amount, receiving web page, receipt date), product garage, and handle affected person data (e.g., affected person identify, age, illness manifestation, selection of doses administered according to affected person, different medication administered.)” To verify that is finished, a verification workflow could also be value pursuing and often revising.

W is for Workflow

Monoclonal antibody systems needed to be stood up from scratch for plenty of (if now not all?) healthcare organizations. Relying at the indication and EUA necessities, that can have an effect on the workflow on referrals, exams, prioritization, the affected person enjoy, and extra. This turns into all that a lot more tough after we upload on pandemic surges which purpose web page capability to manage and drug availability to wax and wane.  Don’t disregard to additionally believe the billing (for the management) section which isn’t tremendous instantly ahead or static. Billing CDM codes can also be discovered right here in case you wish to have them.  It truly is going approach past simply verification and documentation workflows.

X, Y, and Z are XYZ

What’s XYZ? Smartly it’s gibberish, similar to a few of how those monoclonal antibody names sound!  It took me months to grasp “bamlanivimab” which is now of no lend a hand in any respect. Which ridiculous identify can we want to familiarize ourselves with subsequent? No less than I’m hoping you might be having a laugh with the names as we attempt to twist our tongues to pronounce them.


Disclosure: The perspectives and reviews on this article are that of the creator and don’t essentially mirror the opinion or coverage of any former, present, or doable long run employer.


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